NEWFANGLED ATI MED SURG
GASTROINTESTINAL DETAILED
ADULT MEDICALSURGICAL PRE-
ASSESSMENT EXAM \ANSWER KEY
A nurse is caring for a client who is experiencing ventricular tachycardia with a
pulse. The rapid response team is at the bedside. What electrical intervention
should be used to correct this dysrhythmia?
External pacing
Synchronized cardioversion
Defibrillation
No electrical intervention is needed - ✔✔✔ANSWER-Synchronized
cardioversion
Synchronized cardioversion is the electrical management of choice for atrial
fibrillation, supraventricular tachycardia (SVT) and ventricular tachycardia with a
pulse.
A nurse is caring for a client with who has hepatitis A. The client asks the nurse
how he might have contracted the virus. Which of the following is a question the
nurse should ask the client?
"Have you eaten any fresh water fish lately?"
,"Have you received a blood transfusion recently?"
"Have you been to a third world country in the past?"
"Do you take any recreational drugs?" - ✔✔✔ANSWER-"Have you been to a
third world country in the past?"
The nurse should understand Hepatitis A is particularly prevalent in third world
countries and may be the cause of contracting the virus from contaminated food or
water.
A nurse is caring for a female client in the emergency department who reports
shortness of breath and pain in the lung area. She states that she started taking
birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min,
respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood
gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and
SaO2 86%. Which of the following is the priority nursing intervention?
Prepare for mechanical ventilation.
Administer oxygen via face mask.
Prepare to administer a sedative.
Assess for indications of pulmonary embolism. - ✔✔✔ANSWER-Administer
oxygen via face mask.
The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are
involved, so the client has respiratory alkalosis. The client's oxygen saturation is
low, so one priority is to administer oxygen via mask attempting to achieve an
oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus
, the priority is to restore oxygenation.
A nurse is caring for an adult client who is experiencing delayed wound healing.
Which of the following interventions should the nurse take?
Monitor serum albumin levels and notify provider if below 3.5g/dL.
Encourage client to limit protein intake to 5 grams/day.
Encourage an intake of 6,000 - 7,000 mL of fluid/day.
Ensure client is consuming at least 1,000 kcal/day. - ✔✔✔ANSWER-Monitor
serum albumin levels and notify provider if below 3.5g/dL.
The nurse should monitor the client's serum albumin levels because a lack of
protein increases the risk for a delay in wound healing and infection.
A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the
following findings should the nurse identify as a manifestation of increased
intracranial pressure?
Hypotension
Tachycardia
Irritability
Tinnitus - ✔✔✔ANSWER-Irritability
The nurse should monitor the client for behavioral changes, such as confusion,
GASTROINTESTINAL DETAILED
ADULT MEDICALSURGICAL PRE-
ASSESSMENT EXAM \ANSWER KEY
A nurse is caring for a client who is experiencing ventricular tachycardia with a
pulse. The rapid response team is at the bedside. What electrical intervention
should be used to correct this dysrhythmia?
External pacing
Synchronized cardioversion
Defibrillation
No electrical intervention is needed - ✔✔✔ANSWER-Synchronized
cardioversion
Synchronized cardioversion is the electrical management of choice for atrial
fibrillation, supraventricular tachycardia (SVT) and ventricular tachycardia with a
pulse.
A nurse is caring for a client with who has hepatitis A. The client asks the nurse
how he might have contracted the virus. Which of the following is a question the
nurse should ask the client?
"Have you eaten any fresh water fish lately?"
,"Have you received a blood transfusion recently?"
"Have you been to a third world country in the past?"
"Do you take any recreational drugs?" - ✔✔✔ANSWER-"Have you been to a
third world country in the past?"
The nurse should understand Hepatitis A is particularly prevalent in third world
countries and may be the cause of contracting the virus from contaminated food or
water.
A nurse is caring for a female client in the emergency department who reports
shortness of breath and pain in the lung area. She states that she started taking
birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min,
respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood
gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and
SaO2 86%. Which of the following is the priority nursing intervention?
Prepare for mechanical ventilation.
Administer oxygen via face mask.
Prepare to administer a sedative.
Assess for indications of pulmonary embolism. - ✔✔✔ANSWER-Administer
oxygen via face mask.
The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are
involved, so the client has respiratory alkalosis. The client's oxygen saturation is
low, so one priority is to administer oxygen via mask attempting to achieve an
oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus
, the priority is to restore oxygenation.
A nurse is caring for an adult client who is experiencing delayed wound healing.
Which of the following interventions should the nurse take?
Monitor serum albumin levels and notify provider if below 3.5g/dL.
Encourage client to limit protein intake to 5 grams/day.
Encourage an intake of 6,000 - 7,000 mL of fluid/day.
Ensure client is consuming at least 1,000 kcal/day. - ✔✔✔ANSWER-Monitor
serum albumin levels and notify provider if below 3.5g/dL.
The nurse should monitor the client's serum albumin levels because a lack of
protein increases the risk for a delay in wound healing and infection.
A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the
following findings should the nurse identify as a manifestation of increased
intracranial pressure?
Hypotension
Tachycardia
Irritability
Tinnitus - ✔✔✔ANSWER-Irritability
The nurse should monitor the client for behavioral changes, such as confusion,
